November - 2012
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Association between intensive care unit–acquired dysglycemia and in-hospital mortalityOmar Badawi, Michael D Waite, Steven A Fuhrman, and Ilene H Zuckerman Crit Care Med, 2012, published ahead of print This page is only available to Crit-IQ subscribers. To view the rest of this review and gain access to our vast array of critical care teaching tools including podcasts, vodcasts, modules, exam preparation tools, teaching aids and much more, login here, or Become a Member to register |
November |
Previous Comments
| The moral of the story is to maintain NORMOGLYCEMIA. Intuitive isnt it? Now with Intensivists erring on keeping BSL levels liberal we will see in a few years the complications of glycosylation and end organ damage in those whose sugar levels were allowed to remain at higher levels during their illnesses. Then there will be another randomised controlled trial by some researcher pursuing a professorship ! wow | |
| not surprised-16 Nov, 2012 06:00:25 PM | |
| We don't know that. We don't know where the boundary between teleologic adaptive response merges with pathological maladaptive dysglycaemia. You're assuming that normoglycaemia in health is the same as normoglycaemia in illness. Assuming these "surrogate" endpoints has been shown in some studies to counterproductive - I'm sure you assumed that better oxygen levels in ARDS would also make sense - except achieving that with higher volume ventilation will harm them | |
| not so sure-17 Nov, 2012 02:59:06 AM | |
| I am not assuming anything here. You jump to conclusions! Only a handful of critically ill patients are hyperglycemic, so it is not an assumption but an observation that most others tend to manage well with Normoglycemia. So logically, it would follow that "keeping things normal isnt bad" FYI, Hyperglycemia is a biochemical perturbation. It may appear innocuous but has very serious long term consequences as a result of protein glycosylation.Insulin infusion to maintain normal BSLs is a simple intervention and can be monitored very easily. In contrast,to challenge your comparison, in ARDS there are major alterations in physical and mechanical properties of the lung, which leads to hypoxia. Trying to achieve Normoxia in ARDS may involve DRASTIC measures ie Nitric Oxide, prone ventilation, increased PEEP, aggressive ventilation strategies, ECMO etc etc which have far reaching consequences. So with heavy sedation and reducing the metabolic demands we tend to accept a lower oxygen level, not because it is better but because it can be achieved with less fuss and effort. Is your comarison valid? I doubt very much. Perhaps a little too naive!! | |
| not surprised-18 Nov, 2012 05:54:36 PM | |
| Hmmmm, interesting. I contest that you are making assumptions, and that the comparison is certainly relevant. I don't think I'm the one being naive. | |
| not so sure-18 Nov, 2012 08:54:38 PM | |
| Maybe we need to use some measure of how much the variability in glucose levels was due to treatment and how much was due to disease. I realise this might sound a little stupid - there will always be some component of variability that is neither innate nor purely driven by external forces but which responds to the new circumstance. On another level entirely there are all sorts of influences behind glycaemia that make its value as a marker more analogous to urine output, and who targets that? Still, the loop gain of the insulin intervention might tell us something: the sad thing is that we'd have to do a new trial because that sort of thing can't be retrieved from retrospective data with any fidelity. Yes I am proposing another (even more) intensive insulin therapy trial. No I don't think it'll happen any time soon. Yes I think there are probably better things to look at, but we are still the specialty of marginal gains, aren't we? | |
| Lewis-22 Nov, 2012 03:57:59 PM | |
| Exactly my point. We can keep intellectualising till the cows come home. In the meanwhile practicality MUST prevail. To keep doing trial after trial, to keep pursuing the all elusive undiscovered ostensibly intellectual reason behind dysglycemia would be such an expensive, time wasting effort. As I said before, most patients exhibit Normoglycemia even in diseased states and are the ones who have improved survival, reduction in infective complications and many other favourable aspects. Hence Normoglycemia must be the target that needs to be maintained. The ones that respond to stress with Hyperglycemia or as someone else put it .. "the maladapted ones" have higher mortality and complications. Trying to achieve really tight BSL also has its downsides. Hence by default, and this is not an assumption (as someone has accused me of) we must keep it simple, pursue normal targets and as an observation watch what happens. This is far better than any randomised controlled trial will achieve. As you can see most of those trials have only complicated the issue and have raised many more questions. Jumping the bandwagon seems trendy. Pseudointellectual questions are abundant. | |
| not so sure-24 Nov, 2012 09:03:07 PM | |
Comment
The authors of this study argue that although NICE–SUGAR demonstrated harm or no benefit, the problem of maintaining glycemic control within the target range was difficult. This short-coming leaves unanswered questions, ie it remains unclear whether TGC could improve outcomes if it...